Wednesday, November 30, 2016

Elements of Health Reform: Lessons Learned

The cat is out of the bag,  the toothpaste is out of its container,  and the genie is out of the bottle.

Trump has been elected.  Tom Price, MD,  a fierce opponents of ObamaCare has been selected as head of HHS,  and Republican leaders have declared repeal and replacement of ObamaCare as first on their legislative agenda.

What are lessons learned from this unlikely turn of events, which will doom Obama's signature domestic program and likely lead to a Republican alternative plan,  as yet unnamed?  What will happen to those 20 million Americans now subsidized on health exchanges and Medicaid?  No one knows at this point, and it is unlikely we will know precisely until months after President's Trump's debut.

In my case,  after 50 years of writing about health reform, I have come to these conclusions.

  • The U.S.  Constitution- The U.S. Constitution,  said by one historian as the greatest legislative compromise, in Western Civilization, is alive and well. Its electoral college provision  held up and will not be overturned. And the checks and balance concept has prevailed, much to the chagrin of Democrats.
  • Failure to Compromise in Bipartisan Nation -Largely because President Obama failed to compromise in designing and implementing the health law,  passing it without a single GOP vote, ObamaCare is now destined for oblivion
  • Rhetoric Not Enough -President Obqma,  a gifted speaker and campaigner,  did not achieve his promised results, filed  to build a Democratic leadership team, and did not listen to the people.  Consequently, he left the Democratic party in shambles
  • Center Right- America is a center-right capitalistic nation that believes in personal responsibility,  economic prosperity,  and equal opportunity rather than government control,  economic stagnation, and equal  outcomes. 
  • Limits of Centralized Government -A centralized government cannot manage individual choices at the level of doctor-patient relationship.
  • Health  Costs Difficult to Control   -Health care costs are difficult to control when comprehensive benefts are offered but not deliveredand because everybody wants to live another day and because , in the words of comedian Berle, "When it comes to my health, money is no obstacle.
  • Demand for Lifestyle Improvement-One of the untold tales of health reform is the demand of aging patients for access to life-style technologies - joint replacements and cardiac stents -  that support their lifestyle.
  • Ignoring of Insurance Risk - ObamaCare did not lower premiums or deductibles because it made calculations of actuarial risks impossible  and did not take into consideration that insurance is based on balances the costs of illness against health.
  • Absolute universal coverage, noble in intent but impossible in attain America, which cherishes choice, individual freedom, and access to the best medicine has to offer,  cannot be acheived in America
  •  Nature of Humanity -  People, being human and not robots,  will continue to behave badly and ignore habits of good health in search of earthly pleasures  as long as health technologies offer an out.
  • Freedom of Choice - Freedom of choice of doctors and health plans and hospitals are part of the fabric of American culture.
  • Benefits of Prosperity - Beleif in economic growth as a universal solvent for most problems is embodied in President Kennedy's statement,  " A rising tide lifts all boats, and in the provess etends to soften or paper over social inequities.
  •   Orwellian Observation - In Animal Farm, George Orwell commented, "Some animals are more equal than others." This applies to health reform, even is Big Brotther is watching.
  • Unequal Blessing, Equal Miseries -  Winston Churchill said, Capitalism offers unequal sharing of blessings,  while Socialism confers equal sharing of miseries.
  • Necessity of Organizations -  In the complicated world o health reform.  most advances require organizations managed  growth and perpetuity operating within the matix of indvidual ezcellence.
  • The fuure excellence of American health care  depends on govenment and private orgnization working in trandem with health professinals.
  • America in the future will have a dual system -  one operating within the context of government government regulations and value-based outcomes and the other based on direct cash contracting of patients with doctors.
  • Political Aprodisiac -  Control of health care is a political aprodisiac .  A broad siocui saftey netw will always be necessay.
  • Governent Innovation  -  You cannot bottle or direct or crate innovation at the federal level,  Spontaenous imaginative individuals seeking better solutions form the bottom up is necessay.
  • Pure Ideologies   - Pure ideiologies, either liberal or conservative  do not usuall owrk.
  • Language of humanism - elegant language of humanism, spiced with straight talk, insprirtion, and humility is a necessary is essential for developing a workable system that does not break the national budget.
  • Limits of IT -  Algorihms and appas, no mater what their scope or ingenuity, will never replace or replace,human intellegence and imgination and ablility to cut to the chase.


 

Saturday, November 26, 2016

Majority in Battleground States and Trump Knew Country Was Headed in Wrong Direction





Why did Trump Win?  Because majority of voters in battleground states knew country was headed in wrong direct?   In poll after poll, nearly 70% of voters in these states said so.  It was a stark statistic, and it rarely changed  by more than  1 or 2 percentage points.
Voters knew something had to change.  And this lust for change elected Trump.
The number foretold where the majority of people stood and how they are likely to vote.
People knew the sluggish economic growth of 2% was wrong.
People knew taxes were too high and regulations were too burdensome for  economic growth.
People know transferring  jobs abroad made no sense.
People know opening up borders to illegal immigrants was misguided.
People know abundant fossil  fuels, especially natural gas and even coal
made for affordable energy and was the engine of American prosperity.
People knew doubling and even quadrupling of health premiums coupled with unaffordable deductions made seeing a doctor, even for routine care, was virtually impossible.
Who, in the main, were these people?  They were the people of Middle America-  skilled workers, small businessmen and women, the common folk – the glue of American society.
The people yearned for straight talk rather than the politically correct jargon of the elite.
The people knew the U.S. Constitution guaranteed that American government was of the people, for the people, and by the people, not of the elite, for the elite, and by the elite. The elite were D.C. politicians, the well-to-do in bicoastal population centers, the newly rich in Silicon Valley,   academics in universities, the college educated and those with advanced,   the heads of corporations, health system, and above all else,  liberal journalists, and media moguls.
Fly-Over Country
The intelligentsia, , concentrated in major cities and on both coast,  spoke mostly to one another.   They were doing fine, getting richer and richer.   They regarded Middle American as fly-over country, populated by consumers of their products and message, a swamp of mediocrity, full of evangelicals deplorables, bigots, misogynists,  racists, homophobes,  none of whom recognized the glories of upper-crust compassion,  globalism,  apps, algorithms,  and the solutions offered by sum, wind, and  fossil-fuel shutdown as the solution to climate change.   They looked upon the middle of America and its ignorant middle class as swamp – a swamp that needed to be drained and converted to higher causes.
The Swamp Fox

Enter the Swamp Fox, Donald Trump..   As a longer-term charter members of the wealth elite, he knew the thinking of the political and commercial establishment.  He sense that that a populist movement as afoot in Middle America- the center right of American politics.  He could feel it in his bones.  He sense in the huge throngs that flocked to his rallies.  He knew that a mix of patriotism,  and a desire for pride in American, and identify as Americans was in the air.   People wanted a return to economic prosperity which he, and he alone, could unleash through tax reductions, loosening of regulations,  repeal of ObamaCare, a plan to make America energy independent ,  and making America proud and great and secure. 
Keys to His Campaign
The keys to campaign were to make Americans proud of themselves,   to promise economic prosperity, to assure them that nationalism transcended globalism,   and to ridicule and outfox his opponents through manipulation of the media.     He mocked his opponents,  lambasted the media, and made himself a constant presence on TV,  social media, and on Twitter.   He questioned the conventional wisdom.  He  declined conventional  funding sources,   he said he did not want to be anybody’s puppet or to be beholden to them.    He financed much of his campaign.  Somehow he became known as the blue-collar billionaire,  the champion of common people.  And, first and foremost, he vowed to drain the swamp  of the  corrupt establishment in all of its form.
ObamaCare
Trump promised to retain Medicare and Medicaid, the faster growing segments of the national debt, while opening up health car to market forces  through expanded health savings accounts and erasure to state line.   A competitive system, he maintained, would be wonderful.     He did not say just how – how to cover the 8 million uninsured now insured in health savings accounts, how to  finance th 12 million who joined Medicaid.  He would delegate Medicaid to the states through block grants, and somehow the states would expand access while reducing costs.
According to an ancient sage,  the fox knows many things, but the hedgehog, who is closer to the gou8nd, knows one big thing.  What is the health system’s one big thing?  What combination of government programs and market-based cased will work for the benefit of all?  What will be Art of the Health care deal?  Time will tell.



Wednesday, November 16, 2016

Silence Not So Golden

We usually  measure a man - or a woman- by what they say, what they do, how they act, and by their body language, how they carry themselves.

But we rarely judge them by what they don't say, what they don't do, what their body language reveals and when they remain silent.

These things seem to be different with President Obama. He is being judged by his silence and delayed comments on controversial issues such as  not using the term "radical Islamic terrorists: his failure to comment on Kate's  Law and the Mexican felon who gunned her down;  his muteness to take the side of the police in police assassinations; his not mentioning  the doubling of health care premiums, the quadrupling of deductibles,  and the narrowing of choices of doctors and health plans; and most recently , his silence in the wake of violent protests against the Trump election.

No doubt Obama regards his silences as a subtle protest social injustices, not worthy of a political correct message.   He may be correct, but his critics say his silences are acts of moral cowardness, of hiding behind his true beliefs.

Silence, it is often said, is golden,
Except, of course, when certain events unfolden,
Then one should seek to clearly express
Of one's failed policies to confess,
Then one's embolden critics one is beholden.

Tuesday, November 15, 2016

Red, White, and Blue

Imagine the United States as a red sea with blue coasts and scattered islands of blue.

The sea is turbulent with white -waves splashing up against the blue coasts and engulfing or threatening to swallow  islands of blue.

Imagine these environmental scene in political terms over the last 8 years and the changes it has wrought.  Under Obama, there are 11 fewer Senate sets, 60 House seats,  14 fewer governorships, and 900 fewer seats in state legislatures.  Now that is a sea change. 

Turning the red seat blue again will be difficult.  It will call for changing Middle America's attitudes towards centralized government.   It will pit the forces of prosperity against the forces of equality.  It will call for Americans to trust Wall Street,  progressives,  academics,  and the elite more than their gut and desire for a place in the sun again.   It will be the desire for choice,  freedom,  and opportunity against mandates, controls, and regulations.  It will require Democrats to discard its aging leadership and its Clintonism attitudes for younger leaders who pay more attention to the need for more economic growth in the nation's midsection where pride in America still reigns supreme.


Thursday, November 10, 2016

Private Independent Practice; The Way It Was , When Time with Other Physicians and Patients Counted

The November 10 issue of the New England Journal of Medicine has an article :The Meaning and the Nature of Physicians' Work."

It opens with this paragraph:

" Medicine was a fundamental order.   Doctors' lounges were central locations  where community internists, specialists, and surgeons ate together, socialized, and 'curb-' each other for patient consultations.  Charts were dept on paper and were often indescribable."

I expressed this picture in my 1988 book And Who Shall Care for the Sick:  The Corporate Transformation of Medicine in Minnesota."

"Remember the good old days  when your fellow physicians were collegial colleagues; when hospitasl were charitable institutions catering to the sick; when youir success depended on your reputation among  your peers; when you built reputations in a year or two and paid off your banker; when you and your office girl handled all your office affairs; when word of your medical skills spread by word of mouth from one patient to another and from one doctor to another; when you were one of the few specialists around; when marketing was unnecessary because being a doctor with good bedside skills was enough, and when advertising was enoggh.  Those days are over for you and hospitals."

And I might add, the gathering of doctors in hospital staff rooms to compare notes, to make referrals to enjoy doctor-to-doctor camaraderie, to share the jobs of practicing medicine are over over.  Now, as a primary care physician you are forced to stay in your office to make ends meet and to make electronic heath record entries and to make 3ends meet because of Medicare, Medicaid, and Health Exchange cuts.  You now have to hand over your hospitalized patients to hospitalists.

Why is this?  Well. it has to do with the corporate transformation of medicine, and the demands of documentation over the needs of doctoring,  Medicine has become a huge business, comprising nearly 20% of GNP.   And it has to do with the ingress of the Internet and the availability of data to anybody and everybody, including insurers, government officials, and consumers themsleves.  And above all else, it has to do with time - the time formerly  spent face-to-face with colleagues in hospital staff room and time spent with with patients.

As the authors of the New England Journal of Medicine piece comment:

" We believe in the coming years, the U.S. medical community will hve to rethink the human-computer interface  and  merge the real patient with the Ipatient. We hve the opportunity to radically redesigned rmedical record systems; initially created for fee-for-service billing, as our organizations shift towards bundled payments, capitation, and risk sharing.  Perhhaps virtual scribes and artificial intelligence  will eventually  reduced our documentation burden.

And perhaps not.   Perhaps the majority of physicians will switch to direct payment and concierge medicine to escape the time-consuming hassles of electronic health records.  If the Trump election reveals anything, it reveals the unpopularity of EHR data among physicians accounts for much  of physician discontent because it consumes time away from patients.   It reveals data documentation has its limits,  as revealed by the false predictions about the election outcome among across the media, policy makers, pundits, and Silicon Valley aficionados.  Data reliability is limited by human data reliability.   The American middle class and blue color workers between the East and West Coasts in fl-over-land  does not rely on or care bout dta.  They car about their livelihoods, their families,l and their cultural traditikns.


As the New England Journal authors conclude,   Among physicians, "technology cannot restore porfessinal satisfactions.  Our professional will have to rebuild a sense of teamwork, community. and the ties that bind us together as human beings.   We believe that will require spending more time with each other and our patients, restoring  some rituals that are meaningful to both us and the people we care for and eliminating those that are not."

Time spent with one another, in other words, is of the essence, and cannot be replaced with data.

Wednesday, November 9, 2016

21 Reasons Why Trump Won Election

The American people had grown sick and tired of:

1.  Of being talked down to in condescending, contemptuous, and deplorable terms.

2.  Of being told what to do, how to live, and how to think.

3.  Of being called bigots, racists, sexists, misogynists and for being belittling for using "politically incorrect language of for simply being evangelicals and Catholics.

4.   Of being regarded as "stupid" about politics; as one millenial in Nevada commented for not joining a health exchange that charged twice what it would cost for simply paying a mandated penalty, "We may be young.    We may be healthy.   But we are not stupid."

5.  Of being incapable of  understanding the nuances of politics and money and federal control.

6. Of being over-regulated and over-taxed and over-controlled  by centralized bureaucrats in Washington.

7.Of being mandated to pay financial penalties for not being insured in order to pay for the care of the sick and elderly.

8. Of being promised explicitly and falsely by the President that they could keep their doctor, health plan, and hospital  ant that where premiums would be $2500 less for a family.

9. Of being told that gainful full-time employment would steadily and inevitably rise even though 95 million Americans had quit looking for a job.

10.Of being deprived of the opportunity to choose their own doctor and health plan or that they would only have the choice of one or two health plans.

11. Of being unable to shop for health care outside of narrow networkds and plans outside of their state of residence.

12.  Of not being informed that every region of the country ultimtely had to have a homogeneous standard of care.

13.  Of being lectured that because of the global economy their wages would be leveled or frozen through integration and trade agreements or that thier job might be eleminated.

14.  Of being instructed that America was not longer an exceptional nation of freedom and opportunity and its neo-colonial nature should be a subject for apology.

15.Of being told that a systemic war on women was being waged by American men.

16. Of being conditioned to believe that independent physicians , acting alone without third party guidance, were incapable of delivering high quality care and must be replaced by teams of data-driven supplemented "providers".

17. Of being informed that only the media, political, academic, financial, or management "establishments  had the wherewithal and know-how to do what was best for the health of the American people.

18.  Of being indoctrinated with the concept that a coalition of vocal  minorities could dominate and silence a mute majority.

19,  Of being told that a combination of solar, wind, and electrical cars would  could supplant American fossil fuels as a source of  affordable energy for American households.

20. Of being pounded with the idea that ordinary blue collar workers  lacked the common sense and technical skills to build and sustain an entrepreneurial, innovative, and fair and balanced  capitalitstic  economy for the common good.

21.   Of being divested of the fact that the greatest compromise of the western world,  the U.S. Constitution, with its checks and balances, still is the best instrument for serving a diverse democracy.